Compositions comprising amino acids for use in the treatment of mucositides in neoplasia patients undergoing radiation therapy and/or chemotherapy

ABSTRACT

Amino acid composition for use in the treatment of mucositis in patients suffering from head and neck cancer, undergoing radiation therapy and/or chemotherapy, the composition comprising an active agent, the active agent comprising the amino acids: glutamine, leucine, isoleucine, valine, lysine, threonine, histidine, phenylalanine, methionine, tryptophan, tyrosine, and cystine, wherein the glutamine:leucine weight ratio is in the range 4.3 to 5.3.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/571,130 filed on Nov. 1, 2017, which is the U.S. national phase ofInternational Application No. PCT/IB2016/052724 filed on May 12, 2016,which designated the U.S. and claims priority to Italy PatentApplication No. 102015000015060 filed on May 14, 2015, the entirecontents of each of which are hereby incorporated by reference.

FIELD OF THE INVENTION

The present disclosure refers to compositions comprising amino acids foruse in the treatment of mucositides in patients suffering fromneoplasia, in particular neoplasia of the cervical-cephalic region,undergoing radiation therapy and/or chemotherapy.

BACKGROUND

In patients suffering from neoplasias of the cervical-cephalic region(also referred to as head and neck cancer), chemotherapy and radiationtherapy have resulted in good control of tumour growth and improvedsurvival rate. However, such patients are often subject to thedevelopment of severe mucositides over large areas of the oral cavity,pharynx and larynx, which are just induced by radiotherapeutic and/orchemotherapeutic treatments. Because of such mucositides, patients oftenbecome unable to consume oral medications, which involves, in somecases, the need to decrease the dose of chemotherapy or to stopradiation therapy with obviously negative results for the patient.

In order to overcome the problems caused by such mucositides induced byantitumor treatments, there have been put into effect various attemptsto control and reduce the occurrence and/or severity of the same, suchas, for example, more attention to oral care, and use of topicalanesthetics and antimicrobials. However, to date, a therapy whichconcretely allows to counteract or at least to reduce the occurrenceand/or severity of such mucositides in this class of patients has notyet been identified.

Glutamine is the most abundant amino acid in our body. It is a primaryfuel, and an essential precursor for the nucleotide biosynthesis inrapidly proliferating cells such as enterocytes, fibroblasts,lymphocytes and macrophages, for which it represents an essential aminoacid. Moreover, glutamine serves as a substrate for glutathionesynthesis and has antioxidant properties.

If exposed to severe stress, the body is unable to synthesize sufficientamounts of this amino acid, resulting in decreased plasma levels ofglutamine. In these conditions, the mucosal immune system is inhibitedand the release of glutamine by muscle tissue is reduced.

It has been shown, moreover, that patients suffering from advanced headand neck cancer, undergoing cytotoxic therapy, develop glutaminedeficiency (1). Over the last two decades, several studies have examinedwhether the glutamine reduced the incidence and severity of mucositisinduced by radiation therapy and/or chemotherapy (2-7), however, withoutreaching a conclusion about the actual role of glutamine in theprevention or treatment of such mucositides (4-6). In the publicationJebb 1994 (6), the authors attest, in fact, that by administering 16grams of glutamine per day significant results in thetreatment/prevention of mucositis were not observed.

The results of a clinical, double-blind, randomized, placebo-controlledstudy on the efficacy of the administration of glutamine to patientssuffering from head and neck cancer (8) were recently published andconcluded that glutamine—when given in a daily dose of 30g—significantly decreases the severity of mucositis induced by antitumortreatments. In this publication, it is also stated that concentrationsof glutamine between 10 and 26 grams/day are ineffective for thetreatment of mucositis. The hematochemical data of patients subject ofthe study (8) demonstrate, however, a worsening of several parameterscompared to the control group. In particular, there get worse totalneutrophil count and total leukocyte count, hemoglobin, creatinephosphokinase, as well as iron and zinc, which implies, in thesepatients, the occurrence of a greater appearance of local and systemicbacterial infections, asthenia at rest and fatigue during motor activityresulting in increased cardio-respiratory work, reduced ability toproduce muscle energy, decreased multidistrict antioxidative capacity.Finally, these situations cause, especially in the elderly, impairedcognitive function. In summary, a negative state of these parametersmakes the patient much more “fragile”.

SUMMARY OF THE INVENTION

The present disclosure has the purpose of providing amino acid basedcompositions for use in the treatment of mucositides in patientssuffering from neoplasia of the cervical-cephalic region, undergoingradiation therapy and/or chemotherapy, which allow to reduce theoccurrence and/or severity of mucositides and, at the same time, tocounteract the oxidative stress and the inhibition of the mucosal immunesystem caused by antineoplastic treatment.

According to the present disclosure, the above purpose is achievedthanks to the object specifically indicated in the claims that follow,which are intended as an integral part of the present disclosure.

One embodiment of the present disclosure relates to a amino acidcomposition for use in the treatment of mucositides in patientssuffering from neoplasia of the cervical-cephalic region, undergoingradiation therapy and/or chemotherapy, comprising an active agent,wherein the active agent comprises the amino acids: glutamine, leucine,isoleucine, valine, lysine, threonine, histidine, phenylalanine,methionine, tryptophan, tyrosine and cystine, wherein theglutamine:leucine weight ratio is comprised in the range 4.3 to 5.3.

The Inventor has found that the compositions herein described are ableto determine i) a reduction of occurrence and/or severity of mucositisinduced by antineoplastic treatment, ii) an improvement of theimmunohaematological framework compared to controls and iii) a reductionof occurrence and/or severity of dysphagia caused by neoplasia itself orby antineoplastic treatment, thanks to an antiinflammatory effect of thecomposition which allows to counteract the onset of anorexia, “fatigue”and/or sarcopenia, and further iv) an improvement of cell metabolism bypreventing a ipercatabolic condition prevalence.

An advantage related to the use of the compositions herein describedresides in the high tolerability of the compositions that may beadministered to these patients even when suffering from dysphagia.

Another advantage linked to the use of the composition described hereinlies in the fact that the use of amino acids in free form comprised inthe active agent allows producing such compositions at a comparativelyextremely low cost with respect to synthetic proteins and growthfactors, through per se known production processes and widely used inthe field of preparing compositions based on free amino acids. The fieldof application of the invention may however also be extended to aminoacids obtained through genetic engineering or any other artificialmethod.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

In the following specification, numerous specific details are given toprovide a thorough understanding of the embodiments. The embodiments maybe implemented without one or more of the specific details, or withother methods, components, materials, etc. In other instances,well-known features, materials or operations are not shown or describedin detail to avoid obscuring aspects of the embodiments.

The reference throughout this specification to “one embodiment” or “anembodiment” means that a particular feature, structure or characteristicdescribed in connection with the embodiment is included in at least oneembodiment. Thus, the phrase appearances “in one embodiment” or “in anembodiment” in various places throughout this specification do notnecessarily all refer to the same embodiment. Additionally, theparticular features, structures or characteristics may be combined inany suitable manner in one or more embodiments. The headings providedherein are for convenience only and do not interpret the scope orpurpose of the embodiments.

In one embodiment of the present disclosure, the amino acid compositionfor use in the treatment of mucositides in patients suffering fromneoplasia of the cervical-cephalic region, undergoing radiation therapyand/or chemotherapy, comprises an active agent, wherein the active agentcomprises the amino acids: glutamine, leucine, isoleucine, valine,lysine, threonine, histidine, phenylalanine, methionine, tryptophan,tyrosine, and cystine, wherein the glutamine:leucine weight ratio iscomprised in the range 4.3 to 5.3, preferably 4.5 to 5.0, morepreferably is 4.5.

Frequently, patients suffering from neoplasia of the cervical-cephalicregion, within 4-5 weeks from the beginning of radiochemotherapy,develop mucositis, dermatitis and soft tissue swelling. These sideeffects are due to the production of reactive oxygen species (ROS) andproinflammatory cytokines (IL-1, IL-6, TNF-α) whose synthesis isstimulated by activation of transcription factors, in particular thenuclear factor-κB (NF-κB).

Clinically, the patient experiences pain, production of thick mucus, drymouth (xerostomia), tissue tumefaction often accompanied by acutedysphagia. It follows malnutrition or even a deterioration of the same,this being present in about 30-50% of cases already at the time ofdiagnosis. Among the causes of pre-treating malnutrition can berecognized odynophagia, mechanical obstruction, dysphagia due to tumorinfiltration and, last but not least, factors such as anorexia and“fatigue”, secondary to direct and indirect tumor production ofproinflammatory cytokines (IL-1, IL-6, TNF).

In addition, it is reasonable to assume that sarcopenia thatcharacterizes the malnourished patient can also affect the musclesinvolved in the swallowing process and thus result in the onset or evenworsening of dysphagia (if pre-existing). It therefore creates a viciouscircle of malnutrition and dysphagia.

In the most of patients in the 3 months following the start of theantitumor treatment, the acute effects are resolved and swallowingbegins to improve.

However, in some patients, the acute inflammation can be so prolonged orexuberant that during the process of tissue repair induced by antitumortherapy the fibrotic phase prevails over the regenerative phase. Itfollows tissue fibrosis, lymphedema and, consequently, late dysphagia(even years later).

Experimental and clinical studies have shown that glutamine (9) i) is anessential precursor (via glutamate) of the synthesis of intracellularglutathione (GSH) (tripeptide with cell protective action againstoxidative stress), and ii) is able to directly and indirectly protect(through the expression of Heat Shock Proteins) the cell from damageinduced by proinflammatory cytokines (antiinflammatory action).

Clinical studies conducted by administering the composition of thepresent disclosure to patients suffering from neoplasia of thecervical-cephalic region and undergoing radiation therapy and/orchemotherapy, have shown that the composition is capable of improvingthe physical condition of patients, by determining i) a reducedoccurrence and/or severity of mucositis induced by antineoplastictreatment, ii) an unexpected improvement in immunohaematologicalframework compared with untreated patients, and iii) a reduction ofoccurrence and/or severity of dysphagia caused by neoplasia itself or byantineoplastic treatment, thanks to an antiinflammatory effect of thecomposition which allows to counteract the onset of anorexia, “fatigue”and/or sarcopenia, and further iv) an improvement of cell metabolism inthese patients by preventing an ipercatabolic condition prevalence.

The experimental data obtained in the clinical study conducted with thecomposition herein described show that the administration of thecomposition—in patients suffering from head and neck cancer andundergoing antineoplastic treatment—for 6 weeks (21 g of glutamine and15 g of essential amino acids/day) reduces the mucositis more than whatit has been shown in the prior art (8) and, at the same time, allows tocounteract oxidative stress (thanks to the antiinflammatory actionexerted by the composition) and the inhibition of the immune system ofthe mucosae caused by antineoplastic treatment and to improve thecellular metabolism (by preventing the onset of hypercatabolism), bydetermining the maintenance of physiological levels of blood albumin andseveral significant parameters of the immunohaematological framework.

In the patients of the control group it was, in fact, observedsignificantly more frequent mucositis and asthenia at rest and fatigueduring motor activity resulting in increased cardio-respiratory work,reduced capability to produce muscle energy, reduced multidistrictantioxidative capacity, worsening of chronic inflammatory state that isrevealed with lymphedema and late dysphagia, as well as with lesscompensated haematological framework.

The experimental data show that, in patients treated with thecomposition herein disclosed, the maintenance of levels of albumin,muscle strength and a reduction in the frequency of mucositis anddysphagia were obtained.

In a completely unexpected way, the Inventor of the present composition,in fact, has demonstrated that the administration of 20-25 g/day ofglutamine supplemented with 15-20 g/day of essential amino acids (i.e.leucine, isoleucine, valine, lysine, threonine, histidine,phenylalanine, methionine, tryptophan, tyrosine, and cystine) allows anuse of glutamine in various body areas, especially in immunocompetentcells and tissues, more than it can be derived only by exogenousglutamine. In addition, the composition allows to maintain (not shown inthe prior art as indicated for example in the publications (8) and (10))unaltered levels of hemoglobin, albumin, total neutrophils andleukocytes.

The composition object of the present disclosure allows, in fact, toenhance multidistrict protein syntheses in the presence of a systemicand regional inflammatory state in existence of hypercatabolism, whichis then contrasted and brought back to a cell physiological metabolicstate. Counteracting the hypercatabolism allows, in fact, to preservethe integrity of tissues, stimulate the reparative processes andpreserve the proper functioning of the immune system, mainly to oralmucosa level.

In a preferred embodiment, the composition of the present disclosure hasa composition (expressed as a single dose, 12 mg sachet of total aminoacids) as shown in the following Table 1.

TABLE 1 Amount % w/w Preferred by weight based on Range range Ingredientmg/sachet total % w/w % w/w L-Glutamine 7000.00 58.33 50-65 55-60L-Leucine 1562.50 13.02 10-15 12-14 L-Isoleucine 781.25 6.51 4-8 5-7L-Valine 781.25 6.51 4-8 5-7 L-Lysine 812.50 6.77 4-8 5-7 L-Threonine437.50 3.64 2.5-5   3-4 L-Histidine 187.50 1.56 0.5-2.5 1-2L-Phenylalanine 125.00 1.04 0.5-2.5 0.5-1.5 L-Methionine 62.50 0.520.3-0.7 0.4-0.6 L-Tryptophan 25.00 0.21 0.1-0.4 0.1-0.3 L-Tyrosine 37.500.31 0.1-0.5 0.2-0.4 L-Cystine 187.50 1.56 05.-2.5 1-2 Total weight12000.00 100%

The present composition may also comprise, in preferred embodiments,thickening agents that—originating a composition in gel form—allow thecomposition intake by patients suffering from dysphagia caused byneoplasia itself or late onset of the same due to the non-physiologicalmetabolic state.

The thickening agents that can be added to the amino acid compositiondescribed herein, can be selected in the group consisting of xanthangum, methylhydroxypropylcellulose, konjac gum, konjak glucomannan,arabic gum (acacia gum), modified starches. Preferably, the one or morethickening agents are present in an amount between 2% and 30% by weight,preferably between 4% and 15% by weight, with respect to the activeagent weight.

The presence of one or more of such thickening agents allows to thickenthe liquid, preferably water, wherein the composition is dispersedbefore consumption, giving rise to a composition with an ideal viscosityfor the ingestion by a patient suffering from dysphagia.

It is known that people suffering from dysphagia generally lack ofproper muscle coordination and control to properly close the trachea ordo not have the ability to properly push down the entire alimentarybolus and/or beverage to the stomach. It is therefore extremelyimportant that foods consumed by dysphagic patients have the rightviscosity and consistency.

The amount of liquid to add to the composition described herein willdepend, for example, on the consistency to be obtained. This parameterwill be evaluated and determined by a skilled person, taking intoaccount also the degree of dysphagia of the patient.

In some embodiments, the composition described herein further comprisesvitamins, preferably selected from vitamin B1, vitamin B6 and vitamin C.In a further embodiment, the composition also includes carbohydrates,additives and/or flavourings.

Preferred carbohydrates can be chosen from various types ofmaltodextrins. The additive may be selected from tribasic sodium citratedehydrated, aspartame powder, acesulfame potassium, sucralose. Apreferred flavouring is banana flavour.

According to some embodiments of the present disclosure, the preferredisoleucine:leucine weight ratio ranges from 0.20 to 0.70, preferablyfrom 0.40 to 0.60 and/or the valine:leucine weight ratio ranges from0.20 to 0.80, preferably from 0.40 to 0.70.

In a further embodiment, the threonine:leucine weight ratio ranges from0.15 to 0.50, preferably from 0.20 and 0.45 and/or the lysine:leucineweight ratio ranges from 0.15 to 0.60, preferably from 0.30 to 0.55.

In another embodiment, the leucine:isoleucine:valine weight ratio isequivalent to 2:1:1.

In a further embodiment, assuming that the sum of leucine, isoleucine,valine, threonine and lysine is 1, the overall amount of the furtheressential amino acids can further range from 0.02 to 0.25 (i.e.1:0.02-0.25), preferably from 0.05 to 0.15 (i.e. 1:0.05-0.15), stillintended as weight ratio.

In a further embodiment, cystine is present in a weight amount comprisedbetween 150% and 350% of methionine.

In some embodiments, tyrosine is present in the composition in an amountcomprised between 15 and 50%, preferably between 20 and 35%, of theweight amount of phenylalanine.

In a further embodiment, the active agent consists of the amino acids:glutamine, leucine, isoleucine, valine, lysine, threonine, histidine,phenylalanine, methionine, tryptophan, tyrosine and cystine, wherein theglutamine:leucine ratio is between 4.3 and 5.3, preferably between 4.5and 5.0, more preferably is 4.5.

In one or more embodiments, as shown in Table 1 and in the followingTable 2, the amino acids included in the composition consist exclusivelyof the amino acids of the active agent i.e. glutamine, leucine,isoleucine, valine, lysine, threonine, histidine, phenylalanine,methionine, tryptophan, tyrosine and cystine; the composition is free ofany other further different amino acids.

In one or more embodiments, glutamine is present in an amount between 50and 65%, preferably between 55 and 60% by weight with respect to thetotal weight of the active agent.

Furthermore, in particular, when preparing the compositions according tothe instant disclosure, and specifically the active agent, the aminoacids serine, proline, glycine, alanine, glutamic acid and, above all,arginine are preferably avoided, given that they can becounterproductive or even harmful in some concentrations orstoichiometric ratios with the said formulation.

The above mentioned amino acids can be replaced with their respectivepharmaceutically acceptable derivatives, that is salts.

Preferably, the composition is in the form of a dry powder and, in orderto be administered to the patient it is dispersed in a liquid,preferably water. Further specifications, in terms of quantity andratios between the various amino acids provided by the compositions foruse in the treatment herein disclosed, are contained in the appendedclaims, which form an integral part of the technical teaching providedherein in relation to invention.

The results provided herein show that thanks to the composition hereindisclosed it is possible to obtain:

-   -   a significant reduction of grade 3 mucositis (25% vs 55%)        (p<0.05);    -   a late onset of grade 3 mucositis (23.3±3.6 days vs 38.5±4.9        days) (p<0.001);    -   a better blood framework, wherein the levels of albumin, total        neutrophil count, total leukocyte count and haemoglobin are        maintained unaltered;    -   a maintenance of muscle strength (measured with a hand-grip) at        the end of treatment (+0.4 kg vs −7 kg) (p<0.05). This finding        is significant with respect to the prevention of generalized        sarcopenia and it is suggestive, for the correlation between        muscle strength and swallowing, of a possible minor dysphagia;    -   a trend (p 0.056) toward less perceived fatigue, assessed by        FACT-HNSI scale.

Materials and Methods

Patients

Patients with oropharyngeal neoplasia, candidates for radiation therapy(RT) or radiochemotherapy (RCT). Exclusion criteria: severe weight loss(>5% in 1 month or >10% in 6 months), inadequate ingesta (<60% ofrequirements), severe dysphagia, kidney failure, liver failure,palliative radiation therapy.

Study Design

Blind pilot study, with randomization in 2 groups, using automaticallygenerated numerical sequence: study group (G, 20 patients) and controlgroup (C, 20 patients). In the study group the composition hereindisclosed was orally administered in gel form, in the amount of 3sachets/day, far from meals, from 7 days before the start of treatment(T −1) and up to completion of the same (6 weeks).

Patients were subjected to the following regimen of radiation therapywith intensity-modulated beams (IMRT): total dose of radiation 66-70 Gy(1 session/day for 5 days/week). Associated chemotherapy (15 patients inthe study group and 15 patients in the control group) included:cisplatin i.v. 40 mg/m² (weekly) or 100 mg/m² (every three weeks).

The following primary endpoints were evaluated: incidence, severity andonset timing of mucositis. As secondary endpoints there were considered:mucositis-related symptoms, life quality, nutritional status, musclestrength, need for oral integration/artificial nutrition,discontinuation of treatment.

In both groups it was used, in combination with RT or RCT, the sameprotocol of prevention/treatment of mucositis (as required).

All patients were subjected at T-1 and then, weekly, (T0-T6) to amedical examination and dietetic counseling. At each meeting, there werecarried out the following evaluations: presence of mucositis-relatedsymptoms (PROMS scale), life quality (FACT/HNSI NCCN scale), nutritionalstatus (weight, blood sampling for tests, ingesta per os through fooddiaries of the past 3 days), muscle strength using hand-grip (averagedover three determinations with Jamar dynamometer).

The energy requirement has been set in 30 kcal/kg/day, the proteinrequirement has been set in 1.5 g/kg/day.

In patients with inadequate intakes there have been used oralsupplements (ingesta≥60% of requirements) or NA (ingesta<60% ofrequirements).

The assessment of the severity and onset timing of mucositis was carriedout on a weekly basis, by a radiotherapist, using the WHO scale.

Statistic Analysis

Student's t test, Chi Square, Fischer test, Kaplan-Meier curve.

The Composition

The study group (group G) received the composition herein disclosed thatprovided 36 g of amino acids/day (12 g three times a day diluted in halfa glass of water until the discharge of the patient).

The amount of each amino acid contained in the single dose of thecomposition administered to patients is provided in Table 2.

TABLE 2 Ingredient mg/sachet L-Glutamine (146)* 7000.00 L-Leucine(131.17)* 1562.50 L-Isoleucine (131.17)* 781.25 L-Valine (117.15)*781.25 L-Lysine (146.19)* 812.50 L-Threonine (119.12)* 437.50L-Histidine (155.16)* 187.50 L-Phenylalanine (165.19)* 125.00L-Methionine (149.21)* 62.50 L-Tryptophan (204.23)* 25.00 L-Tyrosine(181.19)* 37.50 L-Cystine (240.30)* 187.50 Total weight 12000.00*Molecular weight by “Amino Acid, Nucleic Acids & Related Compounds -Specification/General Tests”, 8^(th) Edition, Kyowa Hakko Kogyo Co.,Ltd.

As can be seen from Table 2, the glutamine:leucine weight ratio ispreferably 4.5:1; the weight ratio between leucine, isoleucine andvaline is preferably equivalent to 2:1:1. The Table 1 also shows thatthe individual amounts of histidine, phenylalanine, methionine andtryptophan are preferably decreasing (that is, the amount of histidineis greater than that of phenylalanine, which is greater than that ofmethionine, which is greater than that of tryptophan) and the amount(weight in grams or moles) of cystine is preferably greater than that oftyrosine. The composition does not contain any other amino acids inaddition to glutamine, leucine, isoleucine, valine, lysine, threonine,histidine, phenylalanine, methionine, tryptophan, tyrosine and cystine.

The amino acid composition also preferably includes carbohydrates,vitamins, flavourings and other pharmaceutically acceptable excipients,as well as in some cases thickening agents to allow the administrationof the composition to dysphagic patients.

In Table 3 there are provided further examples of different variants (A,B and C) of the composition object of the present disclosure. Thecompositions designated A, B and C contain, in fact—in addition to theamino acids indicated in table 1—other additives in various qualitativeand quantitative combinations, such as carbohydrates, vitamins,flavouring agents and thickening agents.

TABLE 3 A B C Ingredients mg/sachet Maltodextrins 11480.07 12514.8010294.77 L-glutamine 7000.00 7000.00 7000.00 L-leucine 1562.50 1562.501562.50 Xanthan gum — — 1100.00 L-lysine 812.50 812.50 812.50 Citricacid 800.00 — 600.00 L-isoleucine 781.25 781.25 781.25 L-valine 781.25781.25 781.25 L-threonine 437.50 437.50 437.50 Sucrester 200.00 200.00 —Lemon flavour 200.00 — 200.00 L-cystine 187.50 187.50 187.50 L-histidine187.50 187.50 187.50 L-phenylalanine 125.00 125.00 125.00 L-methionine62.50 62.50 62.50 Hydroxypropylcellulose 60.00 500.00 Aspartame 40.00 —48.00 L-tyrosina 37.50 37.50 37.50 Polyvinylpyrrolidone 34.70 — —L-tryptophan 25.00 25.00 25.00 Acesulfame k 20.00 — 28.00 L-ascorbicac. - vit. C 15.385 15.385 15.38 Beta carotene 1% 4.00 Tyaminehydrochloride - 0.194 0.194 0.194 vit. B1 Pyridoxine 0.182 0.182 0.182hydrochloride - vit. B6 Total weight mg 25000 25000 25000

First, the compositions shown in Table 3 are prepared by loading, in afour-way mixer, L-phenylalanine, L-tyrosine, L-tryptophan, vitamin B1and vitamin B6 with L-Lysine, in order to obtain a pre-mix. Thecomposition in % of the pre-mix is shown in following Table 4.

TABLE 4 Ingredients % Maltodextrins 83.296 L-Phenylalanine 8.333L-Methionine 4.167 L-Tyrosine 2.500 L-Tryptophan 1.667 Vitamin B1 0.019Vitamin B6 0.018

The ingredients are mixed for a period of 10 minutes to obtain ahomogenous pre-mix.

The remainder of the ingredients listed in Table 3 are loaded in thefour-way mixer and mixed for a period of 20 minutes to obtain ahomogeneous final composition.

The composition object of the present disclosure is added and dispersedin a liquid, preferably water. The amount of liquid to add to thecomposition described herein depends, for example, on the consistency tobe obtained. This parameter is evaluated and determined by a personskilled in the field also taking into account the degree of dysphagia ofthe patient.

Results

The administration of the composition herein described to the group ofstudy patients allowed to obtain a significant reduction of grade 3mucositis (25% vs 55% of controls) and a late onset of grade 3 mucositis(23.3±3.6 days vs 38.5±4.9 days of the control group), as shown by thedata reported in Table 5.

TABLE 5 No. patients of No. patients of study group control groupMucositis Start of End of Start of End of level treatment treatmenttreatment treatment 0 20 2 20 0 1 0 9 0 4 2 0 4 0 5 3 0 5 0 11

In addition, a preservation of muscle strength (measured by hand grip)at the end of treatment (+0.4 kg vs −7.0 kg in the control group) wasobserved. This finding is significant with respect to the prevention ofgeneralized sarcopenia and for the correlation between muscle strengthand swallowing capacity, with a consequent dysphagia reduction ofpatients in the study group.

Also the tendency towards asthenia (assessed by FACT-HNSI scale—p=0.056)is significantly reduced in patients in the study group compared withpatients in the control group.

The composition object of the present disclosure allows, in fact, toenhance multidistrict protein syntheses in the presence of a systemicand regional inflammatory state in the occurrence of hypercatabolism,which is then counteracted and brought back to a cell physiologicalmetabolic state, considering the severe radiochemotherapeuticintervention to which the patients of the study group are subjected. Thecomposition is able to counteract the hypercatabolism and then tomaintain the tissue integrity, stimulate the reparative processes andpreserve the proper functioning of the immune system, mainly to oralmucosa level.

Clinical data, below, show a general maintenance of the most importantblood parameters related to catabolism, as is evident from the datashown in Table 6.

TABLE 6 Patients of Patients of study group control group Start of Endof Start of End of treatment treatment treatment treatment Neutrophil4.237 ± 0.98 4.034 ± 0.872 4.339 ± 1.028 3.736 ± 1.236 count (×1000/mmc)Leukocyte  1.520 ± 0.623 1.147 ± 0.732 1.481 ± 0.754 0.902 ± 0.812 count(×1000/mmc) Hemoglobin 12.67 ± 1.34 11.93 ± 1.76  12.51 ± 1.73  10.47 ±1.98  (g/dl) PCR (mg/dl) 0.34 ± 0.6 0.32 ± 0.57 0.40 ± 0.65 0.43 ± 0.69Albumin 4.49 ± 0.3 4.27 ± 0.45 4.38 ± 0.39 3.87 ± 0.49 (g/dl) Hand grip 35.05 ± 16.96 35.47 ± 14.12 37.12 ± 14.0  30.18 ± 13.76 (kg)* Weight(kg)  69.9 ± 20.9 66.3 ± 19.8 71.5 ± 18.9 66.4 ± 17.0 *p < 0.05

In particular, total neutrophils, total leukocytes, hemoglobin andalbumin, contrary to what reported in Tsujimoto et al. (8) with a dosageof 30 grams of glutamine alone, are maintained in an almostphysiological level and do not decrease over time as observed inpatients of the control group.

In particular, it is evident that the present composition allows toobtain unexpected results compared to the data provided in (8) whereinduring the study period, the treated group showed worseimmunohaematological analytical data compared to placebo. In (8), intreated patients there is a reduction of levels of total neutrophilcount, total leukocyte count, hemoglobin, while there is an increase ofthe levels of creatine phosphokinase (CPK), wherein a CPK level thatgrows over time is related to cellular synthesis damage and reduced useof energy-ATP.

The experimental data provided herein demonstrate that patientsreceiving the composition of the present disclosure will not be subjectto frequent local and systemic bacterial infections, and will presentless frequent asthenia and fatigue at rest during motor activity.Patients in the study group maintain, in fact, the ability to producemuscle energy.

In summary, the maintenance of the physiological levels of the aboveparameters allows the patient to be more tonic and less subject tofatigue during the motor activity, with good management of thecardio-respiratory work, maintaining the ability to produce muscleenergy, and the multidistrict antioxidative capacity. Finally,especially in elderly, no impairment of the cognitive functions has beenobserved.

REFERENCES

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1. A method of treating mucositis in a patient who is suffering fromneoplasia of the cervical-cephalic region and who is undergoingradiation therapy and/or chemoradiotherapy, the method consists of: (1)selecting an amino acid composition for use in the treatment ofmucositis in the patient who is suffering from neoplasia of thecervical-cephalic region and who is undergoing radiation therapy and/orchemoradiotherapy, the amino acid composition comprises an active agent,said active agent consists of the amino acids glutamine, leucine,isoleucine, valine, lysine, threonine, histidine, phenylalanine,methionine, tryptophan, tyrosine, and cystine, wherein (a) the aminoacid composition is free of any further different amino acids, (b) theglutamine:leucine weight ratio is in the range 4.3 to 5.3, and (c)glutamine is present in an amount between 50 and 65% by weight withrespect to the total weight of the active agent, (2) administering theamino acid composition to the patient to treat mucositis in the patientwho is suffering from neoplasia of the cervical-cephalic region and whois undergoing radiation therapy and/or chemoradiotherapy.
 2. The methodaccording to claim 1, wherein the leucine:isoleucine:valine weight ratiois equivalent to 2:1:1.
 3. The method according to claim 1, wherein theisoleucine:leucine weight ratio is in the range 0.2-0.7, and/or thevaline:leucine weight ratio range is in the range 0.2-0.8.
 4. The methodaccording to claim 1, wherein the threonine:leucine weight ratio is inthe range 0.15-0.50, and/or the lysine:leucine weight ratio is in therange 0.15-0.60.
 5. The method according to claim 1, wherein the aminoacid composition further comprises at least one of: carbohydrates, atleast one thickening agent, at least one vitamin, pharmaceuticallyacceptable excipients, and flavouring substances.
 6. The methodaccording to claim 5, wherein the at least one thickening agent isselected from the group consisting of xanthan gum, cellulose andderivatives thereof, konjak gum, konjak glucomannan, Arabic gum,modified starches.
 7. The method according to claim 5, wherein the atleast one vitamin is selected from vitamin B1, vitamin B6, vitamin C. 8.The method according to claim 1, wherein the glutamine is present in anamount between 55 and 60% by weight with respect to the total weight ofthe active agent.
 9. The method according to claim 3, wherein theisoleucine:leucine weight ratio is between 0.4-0.6.
 10. The methodaccording to claim 3, wherein the valine:leucine weight ratio range isbetween 0.4-0.7.
 11. The method according to claim 4, wherein thethreonine:leucine weight ratio is between 0.20-0.45.
 12. The methodaccording to claim 4, wherein the lysine:leucine weight ratio is between0.30-0.55.